For Women Only:
I understand the above information is necessary to provide my dental care in a safe and efficient manner. I have answered all the questions truthfully and to the best of my knowledge.
Correct answers to the following questions will allow our dentists to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential.
By signing this credit policy I acknowledge that I have read and agree to the above statements.